Activity #2 
1.In pairs, read the extract from the ADCS paper, paraphrase and write your understanding in the padlet provided below. Use the QR Code to access Padlet.
2.Answer the questions:

1.   Explain why serious case reviews are required. (4.1)
 
2.   Analyse how serious case reviews inform practice. (4.2)
3.Reference the website using the HARVARD STYLE OF REFERENCING 
4.Be ready to share your findings with your classmates

Learning from serious case reviews. Some feedback from discussions between the College of Social Work, NSPCC and SCIE
Serious Case Reviews (SCRs) are one of the mechanisms through which organisations can learn to protect children better. Reviews which focus on identifying learning can help organisations to change, and become environments in which both the systems and practice can be safely challenged and improved.
In recent years, the spotlight has turned again to SCRs, questioning why they appear to have led to little practice improvement. The Munro Review of Child Protection included specific consideration of the role of SCRs. The Review’s final report (Munro, 2011) affirms the importance of ensuring that SCRs establish not merely a description of what professionals did, but also an analysis of why they acted as they did. Professor Munro also suggested that SCRs may be able to learn from developments in accident investigation techniques in other sectors, particularly the ‘patient safety’ agenda in health and accident investigation in aviation. Working Together to Safeguard Children (Her Majesty’s Government, 2013) recently revised (Her Majesty’s Government, 2015) reflected the Munro Review (ibid.) recommendations. The statutory guidance focuses on requiring that SCRs provide good explanations of why professionals acted as they did, but without detailed specification of the SCR process, as Part 8 of the previous guidance had done. Under the new guidance, LSCBs are able to use any credible SCR methodology. Working Together 2013 also announced the establishment of an independent national panel to: “support Local Safeguarding Children Boards (LSCBs) in ensuring that appropriate action is taken to learn from serious incidents in all cases where the statutory criteria are met and to ensure that those lessons are shared through publication of final SCR reports.”
Serious Case Reviews – understanding practice There is a real risk that retrospective case reviews will provide narratives which imply inevitability in the chain of events which result in serious harm or abuse and which therefore could (and should) have been predicted and prevented. That certainty in reality does not exist. Safeguarding decisions are almost always judgements based on incomplete evidence, frequently weighing competing risks and managing conflicts between the rights of different individuals. Evaluations of risk are judgements based on known risk factors, but these are rarely clear cut. By definition, judgement is just that and not a mechanistic process with a right or wrong answer (Munro, 1996). SCRs need to develop an understanding of the ‘local rationality’ of events and practitioners at the time, and avoid applying ‘hindsight bias’ (Munro, 2011). Research and experience do not provide a fail-safe framework for judgements and this should not be implied. This means that it is important that SCRs provide a more nuanced understanding of the contextual factors underlying human judgement and mis-judgement (e.g. Dale and Mills, 2013) – so that improvement effort can be aimed at improving underlying conditions to support professional judgement, rather than just trying to further prescribe and control the role of individual professionals and allocate blame. Organisational learning and change in practice It is helpful in this context to distinguish between learning and improvement. Working Together 2015 indicates that the focus of SCRs should be on providing explanations for why mistakes and poor practice occur. Understanding the underlying reasons is not an end in itself, but is vital to informing improvements to practice. Such learning can be thought of as diagnostic, a necessary precursor for change and improvements to practice, and needs to be shared across LSCBs at local, regional and national levels. However, action is then required in order to lead to improvement. We know that there are a number of factors that can help learning from SCRs: 1. Getting the right kind of explanations and information – Changes and improvement to practice need to be based on a detailed understanding of the reasons underlying poor practice. SCRs should therefore have a focus not just on ‘what’ happened in a case, but why – including consideration of the organisational context and systemic factors. 2. Making the SCR a key element in a change process – Meaningful involvement of staff, managers and senior managers in the process means that the SCR initiates the process of change by cultivating ownership amongst frontline staff and managers. 3. Recommendations which encourage a realistic and strategic approach to change – In the past, SCRs have led to action plans with large numbers of SMART1 recommendations, which can encourage an over-simplistic and mechanistic approach to change. Recommendations need to be forward looking, less concerned with planning and process and more focused on providing Boards with strategic challenge and reflection. . 4. Leadership that demonstrates learning to improve – Changing multi-agency practice is unlikely to be straightforward or linear. Change depends on the actions of people at all levels of an organisation, shaped by organisational cultures, as well as written documents and strategies. SCRs should be seen in a wider context of learning and improvement, and of improvement priorities within different agencies.

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